Gestione chirurgica degli Incidentalomi surrenalici: analisi della casistica e sviluppo di modelli decisionali per la terapia personalizzata

Introduction Adrenal incidentalomas constitute a heterogeneous spectrum ranging from hormonally active to non-functioning lesions, with cross-cutting consequences for cardiovascular function and metabolic homeostasis. The expanding use of minimally invasive adrenalectomy calls for decision pathways that integrate pathophysiology, oncological risk, and procedural safety. Aim To characterise phenotype distribution and clinical–surgical outcomes in a high-volume centre; to assess the safety and effectiveness of minimally invasive adrenalectomy by subgroup; to examine the association between BMI and bone health; and to propose predictive tools to support personalised surgical indications. Materials and methods Single-centre observational study (2015–2025) in a high-volume endocrine surgery unit, considering a cohort of 1,754 patients, of whom 275 (15.7%) were diagnosed with diagnosis of adrenal incidentaloma. Consecutive adults referred for adrenal lesions were included; an “incidentaloma” was defined as an imaging finding not suspected on clinical grounds. The care pathway combined (i) standardised hormonal screening, (ii) multiparametric radiological characterisation, and (iii) skeletal assessment with baseline DXA in at-risk individuals or in mild hormonal autonomy. Treatment decisions were reached by a multidisciplinary board, favouring laparoscopic/robotic approaches and reserving open surgery for selected cases. Outcomes comprised blood-pressure and metabolic trajectories, complications, conversions/transfusions, and skeletal endpoints (BMD/Low BMD). Statistical analysis used χ²/Fisher and Welch/Mann–Whitney tests, plus multivariable logistic regression to estimate odds ratios with 95% confidence intervals. Results Of 1,754 individuals assessed, 275 (15.7%) had an adrenal incidentaloma: 192 (69.8%) nonfunctioning and 83 (30.2%) functioning. Operability was markedly higher in functioning lesions (86.7%) than in non-functioning ones (10.9%; OR 53.30, 95% CI 24.44–116.24; χ²=145.43; p=1.73×10⁻³³). Low BMD was more prevalent in the incidentaloma cohort vs controls (74% vs 25%; p<0.001), with an independent association between BMI and Low BMD (OR 1.25, 95% CI 1.05–1.50; p=0.020); mean BMI was higher in the incidentaloma group (27.8±4.2 vs 26.1±4.6kg/m²; p=0.010). Minimally invasive surgery was the final standard (≥85–100% across subgroups), with 4/93 conversions overall and low transfusion use. Conclusions Minimally invasive adrenalectomy is safe and well standardized surgical procedure, with the clearest gains in hormonally active phenotypes. Skeletal endpoints, together with BMI and imaging, should perform personalised indications. Purpose-built predictive tools can shift decisions from fixed thresholds to individualised benefit–risk estimates. Prospective multicentric trials are necessary in order to validate these preliminary results.